Flexible Goals & Strategies for Change: An Integrative Approach

1. Flexible Goals & Strategies for Change:An Integrative Approach Arnold M. Washton, Ph.D. RECOVERY OPTIONS New York, NY & Princeton, NJ

2. Websites • www.RecoveryOptions.us • www.ModerateDrinkingOptions.com

3. References & Recommended Reading • Motivational Interviewing (Miller & Rollnick) • Practicing Harm Reduction Psychotherapy (Denning) • Harm Reduction Psychotherapy (Tatarsky) • Working with the Problem Drinker (Berg & Miller)

4. References & Recommended Reading • The Heart of Addiction (Dodes) • Addiction and the Vulnerable Self (Khantzian..) • Substance Abuse Treatment and Stages of Change (Connors et al.) • Rethinking Drinking (RethinkingDrinking.niaaa.nih.gov)

5. Arnold M. Washton, Ph.D. Joan E. Zweben, Ph.D. Guilford, 2006

6. Today’s Presentation • Limitations of Current Treatment • Principles & Elements of the Integrative Approach • Assessment, Goal Setting, Specific Treatment Interventions

7. Limitations of Current System • Countless substance users are underserved • Majority are not in treatment • One size does not fit all, no approach is best for everyone • Population is highly diverse: • Severity of substance use & its consequences • Nature and severity of co-occurring disorders • Motivation and stage of readiness for change • Desired treatment goals

8. Limitations of Current System • Many substance users: • Do not want to stop using • Do not accept lifelong abstinence as their goal • Do not embrace the disease model (>95% of U.S. programs) • Unwilling to adopt identity of “addict-alcoholic” • Perceive their problem as not severe enough to warrant what traditional treatment requires (they may be right)

9. Limitations of Current System • Mostly agency based programs • Group therapy is primary modality, individual therapy is scarce • Patients must fit themselves into the program rather than vice versa, especially those with emerging or early-stage problems

10. Limitations of Current System • Current treatment more boilerplate than individualized • Designed to treat mainly high-severity SUDs • Not good fit clients with less severe problems (i.e., abuse) or in early stages of change • Likely to be labeled by treatment providers as “resistant”, “unmotivated”, “in denial”

11. Limitations of Current System • Not everyone with an alcohol or drug problem has the disease of addiction • The more severe a person’s alcohol/drug problem, the better it conforms to the disease model • There are at least four times as many “problem drinkers” vs. alcoholics in the U.S. (NIAAA)

12. Limitations of Current System • Providing flexible alternatives to abstinence-only disease model approaches can potentially attract many more people into treatment before they develop more serious problems • Moderation is a realistic and achievable goal for many people with less severe drinking problems who are not alcoholics • Many people who start with moderation, end up choosing abstinence, including people who would not have entered treatment at all

13. Limitations of Current Treatment System • Many dropouts caused by aggressive confrontation-of-denial and other authoritarian tactics • Lacking more attractive treatment alternatives, many substance users avoid getting help altogether (sometimes with dire consequences)

14. Limitations of Current System • At other end of spectrum are psychotherapists who enable substance users by failing to adequately assess and intervene • Some join patients in seeing substance use as not the “real” problem by focusing instead on underlying emotional and psychological issues

15. Project MATCH Which treatment approach is best? • Large multi-site study funded by NIAAA • Outpatient treatment setting • Compared three of the most widely used treatment approaches

16. Project MATCH • Motivation Enhancement Therapy • Cognitive-Behavior Therapy • 12-Step Facilitation Therapy • Individual therapy format • Delivered by either addiction counselors, clinical social workers, psychologists

17. Project MATCH • No difference between TSF, MET, CBT in retention and outcome • No difference related to therapists recovery status or credential/degree level • Significant differences based on therapists’ clinical style & stance toward patients • Therapists with a more empathic and engaging rather than confrontational style produced the best outcomes!

18. Conclusions The clinician’s therapeutic style, stance, and attitude toward the substance-using client is more important in determining treatment engagement, retention, and outcome than the clinician’s treatment philosophy, degree level, or personal experience with addiction and recovery.

19. Amazing! It has taken over 30 years of clinical research and hundreds of millions of dollars to find out that substance abuse treatment actually works better when clinicians are NICE to the patients !!

20. Bill W. (1955)….. "Real tolerance of other people's shortcomings and respect for their opinions are attitudes that make us more useful to others. Never talk down to an alcoholic ! He must decide for himself whether he wants to go on. He should not be pushed or prodded. If he thinks he can get sober in some other way, encourage him to follow his own conscience. We have no monopoly. We merely have an approach that worked with us. "

21. Principles of Integrative Approach • Non-dogmatic, client-centered, atheoretical approach • Avoids adherence to any single treatment orientation or philosophy in favor of doing “what works” • Utilizes a toolbox of different treatment models, approaches, strategies, and interventions some of which may seem incompatible • Do “what works” • Above all, do no harm!

22. Principles of an Integrative Approach • Brings the basic tenets of psychotherapy into the treatment of SUDs • Puts primary emphasis on the therapeutic relationship • First and foremost goal is to engage patients “where they are”

23. Principles of an Integrative Approach • Consumer friendly, low-threshold entry to treatment • Empowering, motivating, non-authoritarian • Matched to problem severity and patient’s motivation/readiness for change

24. Principles of an Integrative Approach • Designed to approach patients “where they are” rather than where the treatment provider dictates they “should be” • Recognizes the therapeutic relationship and engagement/retention as keys to treatment success • Respects the client’s concerns and definition of the problem as a legitimate starting point for treatment

25. Principles of an Integrative Approach • Comprehensive and able to address the substance use behavior itself, co-occurring disorders, and related emotional/psychological issues with appropriate emphasis and timing • Recognizes a CONTINUUM of SUDs, not only Abuse and Dependence, and a continuum of negative consequences • Recognizes patients’ autonomy and freedom to choose their own treatment goals, regardless of what the clinician might think is best

26. Principles of an Integrative Approach • SUDs are complex behaviors with complex etiologies • Multiple, interacting, often unknown causes • Abstinence provides the greatest margin of safety, but any steps taken to reduce substance-related harm are steps in the right direction • Goals must be client-driven, not diagnosis-driven

27. Principles of an Integrative Approach • Treatment more likely to succeed when patients choose and are personally invested in goals and methods to achieve those goals • Does not require patients to see themselves as “addicts-alcoholics” or accept their problem as a “disease” in order to make meaningful, lasting change

28. Principles of an Integrative Approach • Encourages clinicians to be aware of and appropriately manage negative countertransference reactions (e.g., anger, sarcasm, rejection) toward patients who do not comply with recommendations, continue to use, etc.

29. Principles of an Integrative Approach • Clinicians should not hesitate to inform patients of the risks of continued substance use, the potential value of abstinence, and what type of treatment might be best (including inpatient care, if needed) • Recognizes that clinicians differ in willingness to treat patients who continue to engage in highly destructive patterns of substance use

30. Principles of an Integrative Approach • Appreciation for PSYCHOLOGICAL factors intertwined with addiction • Addiction does not develop in a vacuum • People rarely (if ever) become addicted during a time in their life when they are feeling reasonably happy and self satisfied • Addiction flourishes when people are exposed to chronic inescapable stress that exceeds their coping abilities and they feel powerless to do anything about it

31. Principles of an Integrative Approach • There is a strong connection between adverse childhood experiences (various types of physical and psychological trauma) and later development of addictive disorders • Mood and other psychiatric disorders are neither necessary or sufficient to cause addiction. • Alleviating psychiatric symptoms with medication does not prevent relapse to substance use • Addiction is not in the drug. It is in the person using the drug • The vast majority of people who use “addictive” drugs do not become addicted to them

32. Psychological factors • Disease model explains how chronic alcohol/drug use ultimately changes brain, behavior, and personality, but it does not explain what motivates some people to use these substances intensively and to the point of ending up with an addicted brain

33. Psychological factors • Addiction can be seen as a disorder of affect and self-esteem regulation • Substances are used initially as an attempt to cope • Addiction develops when chemicals are used repeatedly and habitually as coping strategies

34. Psychological factors • Addiction-prone people often lack the ability to reliably identify, modulate, tolerate, and appropriately utilize/express feelings • Addiction develops only to substances that actually work to alleviate problems and/or enhance functioning • Using substances to manage moods and internal affects is maladaptive because it disables the “signal value” of emotions • Without emotional “radar” painful collision with reality is inevitable

35. Elements of Integrative Approach • Stages of Change Modelto accurately match treatment interventions to the patient’s stage of readiness for change • Motivational Interviewingtechniques to facilitate patient engagement and to enhance patient motivation and readiness for change

36. Elements of Integrative Approach • Cognitive-Behavioral Techniques (CBT)to facilitate behavior change, prevent relapse, manage cravings/urges and negative emotions/moods, acquire adaptive non-chemical coping skills as alternatives to habitual self-medication with alcohol/drugs • DBT and ACT to manage overwhelming and disruptive affects/moods

37. Elements of Integrative Approach • Pharmacotherapy to treat co-occurring mood/anxiety disorders, facilitate relapse prevention • Disease Modelto reduce stigma, shame/guilt, to support need for total abstinence, provide “roadmap” for recovery, encourage AA involvement, remove serious risk

38. Elements of Integrative Approach • Harm Reduction Strategies for initial engagement and as incremental approach for patients unwilling to embrace abstinence • Self-Medication Model & Modified Psychodynamic Therapyto address “self-medication” aspects of substance use and other core psychological issues intertwined with the use

39. Self-Medication Model (Khantzian) • Substance use is initially adaptive, an attempt to cope-- with stress, negative emotions, lack of assertiveness, social anxiety, etc… • Because substances instantly reduce negative emotions and enhance functioning, they become extremely powerful and compelling reinforcers

40. Self-Medication Model • Addiction vulnerability stems from deficits in four core areas: affect regulation, self-care, self-esteem, and interpersonal relationships • Feelings often are vague, ill-defined, confusing • Feelings are poorly regulated and poorly tolerated • Feelings are usually acted out (expressed through action), rather than worked out (processed adaptively)

41. Self-Medication Model • Some people are overwhelmed by their feelings (“affective flooding”) • They have an inadequate stimulus barrier and deficient affect management or self-soothing abilities. • They are likely to choose depressant drugs (e.g., alcohol, tranquilizers, opioids)

42. Self-Medication Model • Other people feel too little, have an overactive stimulus barrier, are emotionally numb, lack signal anxiety, and have impaired affect recognition skills (alexithymia) • Lack emotional “radar” which leads to maladaptive behavior (failure to recognize, attend to, and cope with real life problems) • My gravitate toward stimulant drugs such as cocaine or methamphetamine which induce feelings of sexuality, being alive, and the illusion of being emotionally present

43. Stages of Change Model • To facilitate “starting where the patient is” • To enhance patient-treatment matching • To prevent the misalliance of patient and clinician working in different stages of change • Treatment programs usually expect patients to be ready for change, but many are in the early stages of acknowledging the problem, let alone committing to a definitive course of action

44. Readiness to Change Paradigm Is the patient’s goal to reduce or stop use? resistance ambivalence X X X Not considering Change Precontemplation Ready to Change Preparation Taking Action Action Maintaining Change Maintenance Thinking about change Contemplation

45. Five Stages of Change • Precontemplation- Not seeing the behavior as a problem or feeling a need to change it (“in denial”) • Contemplation- Ambivalent, unsure, wavering about necessity and desirability of change • Preparation- Considering options for changing in the near future

46. Five Stages of Change • Action- Committed to a specific action plan, taking specific steps to change behavior • Maintenance (relapse prevention)- Sustaining changes, working to prevent backsliding/relapse [In this model, RELAPSE is defined not simply in terms of substance use per se, but as any regression back to an earlier stage of change]

47. Assessing Readiness to Change • Elicit the patient’s view: How do you see your substance use and to what extent do you see it as a problem? • What concerns you the most about your use? • What do you see as the positive benefits of your substance use, how does it still help you? • What do you see as the potential benefits of reducing/stopping? • What do you see as the potential drawbacks of reducing/stopping and what obstacles that might get in the way • How would you like to proceed?

48. Stage-Appropriate Goals • Precontemplation- Increase awareness, raise doubt • Contemplation- Tip the balance toward change • Preparation- Select the best course of action • Action- Initiate change strategies • Maintenance- Learn and practice relapse prevention strategies • Relapse- Get back on track with renewed commitment to change

49. Choice Motivational Strategies • Normalize client doubts • Amplify ambivalence • Avoid arguments & power struggles • Support self-efficacy • Roll with resistance • Offer choices

50. Motivational Approach • Therapist style exerts a powerful influence on client resistance and readiness to change • Therapist style can either provoke or diminish (side-step) “resistance” • Argumentation, aggressive confrontation, and pressure tactics are poor methods for inducing change • When resistance is evoked the therapist should back off and find a creative way around it